Provider Demographics
NPI:1528045408
Name:TIEDE, WILLIAM S (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:S
Last Name:TIEDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 CENTRAL AVE N
Practice Address - Street 2:STE 220
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1206
Practice Address - Country:US
Practice Address - Phone:952-993-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN31691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND98310Medicare UPIN